The Dreaded Question . . .

Let’s tackle the BIG Q in the realm of dentistry without dentists:  the dreaded extraction. The patient puts up with the pain until it overcomes the dread of getting a tooth pulled, and the operator dreads the thought of the first effort to take a tooth out.  This is the ultimate question and ultimate challenge that will face the local health care “go to” person, no matter who that may be in a TEOTWAWKI situation.   

As with any problem in daily practice for any of us, no matter what flavor of degree, the first task when we are presented with a patient is to use our head and hands to take a good history and perform an examination to reach a diagnosis.  Let’s think about several possible scenarios: 

  1. Someone has fallen, hit his mouth and snapped off a couple of teeth.  Nerves are exposed, edges are jagged, and the patient cannot eat due to the pain.  
  2. The patient is in acute pain, to the point that he cannot think straight.  The patient is hyper and can barely sit still long enough for you to figure which tooth is causing the trouble.  
  3. A knock on the door leads to a person with an eye swollen shut and a face that looks like it holds a lemon under the cheek, or worse . . .
  4. That swelling is below the jaw, the patient is running a high fever, lymph nodes are swollen,  and the patient looks sick as a dog. 
Example of post-operative swelling following t...

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Other than the first scenario where the dental causation is obvious, the operator will have to come to the conclusion that a tooth or teeth are the source of the pathology. In an end-of-the-world situation, there will be very limited options for treatment. There will be emery boards and nail files for smoothing sharp edges, there may be some temporary filling material for filling and soothing cavities. But beyond that … teeth are going to need to be removed. Once we have made the decision that the patient in front of us has a tooth that needs to be removed, someone needs to make it happen, and if there is no dentist around, then it just might fall to you. 

Let me say at this point that extractions range from super-easy (finger or gauze pad easy), to hammer and chisel, one-bit-at-a-time ordeals. I have had in my office extractions range in time from less than 30 seconds to more than 1 ½ hours. Just yesterday I had a tooth break off at the bone line in a patient with rock hard bone, who due to the patient and his distress, was sent to an oral surgeon for sedation for final removal. That is after 35 years of practice amounting to thousands of teeth.

Teeth vary significantly in anatomy. In today’s world, even with a lifetime of studying dental anatomy (or perhaps because of it) I will not attempt to remove a tooth that I do not have an x-ray of.  Some teeth have tiny thin roots, extra roots, roots with L- shape, S-shape, as well as corkscrew bends. Some bone is soft and pliable; some is rock-hard and unbendable.  Lips, cheeks, and the tongue often want to get in the way.

And lastly, let me add that blood is opaque. You cannot see through it. In my office I have a trained assistant constantly suctioning the field to allow me to see what I am doing. Even with all the advantages of a modern facility and equipment, successfully removing a tooth intact is quite an accomplishment. 

Medieval dentist removing tooth

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My point is that taking teeth out is as much an art as it is a science. You can read and study science from a book. Artistry comes from experience and often serving a preceptorship at the feet of a master. It is not to say that every dentist did not start somewhere. My suggestion for the layman to begin the process of training to perform emergency extractions is to find a dentist that is willing to teach as he is extracting teeth. Most communities have a free indigent dental clinic that would be a good place to begin.  True hands-on experiences in extractions are problematic in any first world country, due to the minor problem of the need for a degree and a license, as well as liability insurance.  One of the best places to learn is in a dental mission to a third world country. There is always a need for helpers in these types of settings and volunteers are always welcome.   

Since this is an open forum, I am not going to go into what I can teach about the how-to’s of extractions.  In today’s world, dentists need to handle these issues. Only when a non-dentist is the person of last resort is there any justification for taking the steps to remove a tooth. There is too high a risk of promoting dentistry without a license.

(I am going to leave that to the Medical Pro side of this site.  Please keep checking in as I post several articles of how to handle each type of tooth:  upper anterior (front) 6, upper bicuspids, and upper molars, lower incisors, lower cuspids and bicuspids, lower molars. In addition I will have a piece on what to do if there is a problem.)

Copyright © 2011 WH2THDR 

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About Cynthia J. Koelker, MD

CYNTHIA J KOELKER , MD is a board-certified family physician with over twenty years of clinical experience. A member of American Mensa, Dr. Koelker holds degrees in biology, humanities, medicine, and music from M.I.T., Case Western Reserve University School of Medicine, and the University of Akron. She served in the National Health Service Corps to finance her medical education.
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